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[bpasero]

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Iritis / Anterior Uveitis - Normal Experience?
by bpasero on Sun Feb 03, 2013 11:33 am

I suppose this is the correct way to do this, so here goes. My name is Mason (pen name) and I live in Arizona - mid 30s.

On Jan 15th, about 2.5 weeks ago I had severe itchiness in the inside corner of my right eye. Not typical allergy itch, but an insane itch. Went to my PCP a few days later and they briefly examined me and gave me pinkeye drops (tobramycin), even though there was no discharge. I also told them I had had swollen lymph nodes in my neck/jaw for a week or so before (mainly the one where tongue connects). The NP felt them and confirmed that they were inflamed. On 1/22, just because I felt something was wrong, I went in for a physical and got my blood levels checked. I was called and told everything normal. As best as I can remember, the next day I started noticing blurred vision, particularly around lights. It took me a while to figure this out because, with both eyes together it is almost undetectable. Only after I covered my left, good, eye did I notice that there was a uniform haze over my right eye.

1/29 - I tried to tough it out, so I didn't see an opthamologist until 1/29. The words were, "the good news is, is that we can treat this." I was then told I had iritis, which I had never heard of before, which I was told was swelling of the iris. I was given 1% prednisolone acetate (pred forte) drops, which I started taking every 3 hours. As soon as I could I hit the Internet and started searching.
1/31 - No vision improvement. I wasn't sure if this was typical, so I called the eye doctor. The doc increased the pred dose to every two hours. Told to call back if no change the next day.
2/1 - No improvement - office manager told me to come in (I was on the fence), so I went back to opthamologist (same place different doctor). Doctor told me I had Keratic Precipitates (KP's) in my eye and that my retina was swollen. Rechecked eye pressure and was told to increase dosing to once every hour and to return the next day. Meanwhile, I was given a prescription for homatropine. Unfortunately, I was not able to find a pharmacy that had it in stock. However, my pain at this point was not high so the doctor said it was optional. I had been managing pain by alternating ibuprofen (200 mg) and bromelain (naturopathic anti-inflammatory). Was told I didn't have to wake to take the drops, so I made it a point to not take them during the night. I haven't been sleeping well since starting them, so being awake wasn't a problem.
2/2 - Another eye exam - eye pressure steady, cornea swelling looked to be reduced. Instructions - Pred drops every hour, reduce to every 2 hours on 2/3. Doctor (and myself) optimisitic that I am on the path towards recovery. I have resigned myself to the idea that this might take some time. Doctor also hopeful because KP's were not in back of eye.
2/3 - Eye pain still minimal. However, still have the same uniform film of haze over my right eye due to the KP's. Things seem to have stabilized, which has me optimistic.

Having never heard of iritis / anterior uveitis, I am greatly appreciative of this website. For my particular case, the vision issue is mostly an annoyance. The real challenge is that I can't wrap my head around a cause (at this point in time). The opthamologist said that 70-80% time it subsides on its own and the cause is not known. However, a visit to the mayo clinic website reveals many different (scary) possibilities. At times, I bet most healthy people have had some of the symptoms listed on one of the root causes. For example, I had swollen lymph nodes in my jaw and neck area (which I attributed at first to a flu shot on 1/10). Could be lymphoma? Yikes! I feel I need to get more lab work done just to rest my brain.

Anyway, I will continue to update this as time goes on. I am appreciative of this site as a place to learn and also a place to vent. I have altered my diet trying to reduce pro-flammatory foods, am taking a naturopathic eye supplement (Natural Factors - Eye Factors) and also the ibuprofen / bromelain, drinking lots of water. These things seem to help. I suppose the next step is to go ahead and order the homatropine (it will take a few days). Doctor likened it to a broken elbow. If you don't stop moving it, it will never heal.

Update (I couldn't find the reply button):
I have seen a retina specialist - wants to give it another week to see if there is improvement. Pred drops dosage increased to once every hour (I don't take them at night). Don't really have any headaches now and it doesn't hurt to move my eyeball as it did before (say to look at someone to the extreme right/left). I was also finally able to get dilating drops which I am to take twice per day. However, still a hazy look to the eye. Vision basically the same.

I tried to press the issue of getting tests done, but the specialist said the tests are often inconclusive. For example, the herpes test could show positive for antibodies because I have had canker sores in the past. That said, if no improvement in one week, I expect treatment / testing plan to be get more aggressive. Doctor mentioned chest x-ray, steroid tables and possibly an injection. However, since this is my first case and it is unilateral, I think the doctor wants to be patient.

So now, I am trying to be patient and optimistic. I am holding onto the fact that I am otherwise healthy (no joint pain, shortness of breath, difficulty breathing, normal results full blood panel).

Lastly I haven't heard exactly what type of KP's they are, but I was told level 4, whatever that means.

P.S. Thank you Mike for your help.
Last edited by bpasero on Fri Feb 08, 2013 3:28 pm, edited 2 times in total.
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Iritis / Anterior Uveitis - Normal Experience?
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Re: Iritis / Anterior Uveitis - Normal Experience?
by Mike Bartolatz on Sun Feb 03, 2013 2:22 pm

first of all welcome to the group! with the posterior segment swelling that you mention, and KP's along with the lymph node swelling, you need to be seen by an expert as soon as possible as you might have something like Sarcoidosis as an underlying cause of this.
a biopsy of the lymph node would prove beneficial in getting a diagnosis. the main thing is to make sure that this isn't caused by a pathogen, virus etc.. the steroid eyedrops will NOT treat beyond the iris. the generic ones must be shaken for a minimum of 3 minutes, YES I SAID 3 MINUTES, as the do not suspend well in the fluid in the vial. then after you put in the eyedrop, press in over the inside corner of the eye and allow the eye to absorb the eyedrop otherwise it just goes down the drain into your sinuses and throat leaving the terrible aftertaste. the pupose of the dilating drop is to prevent adhesion between the iris and the lens when inflammation is present. it relaxes the muscle that opens and closes the iris. this helps stop pain from spasming of the muscle when adhesion is present. please ask the doctor what type of Kp's you have going on. if he says they resemble 'mutton fat' then you should be looked at for Sarcoidosis related disease. KP"s don't occur anywhere but on the back of the cornea. the Keratic Part of the term stands for cornea. exudate occurs on the retina and pars plana in Sarcoidosis. it too often appears like mutton fat if I recall correctly. when the inflamation is controlled the exudate goes away and it leaves a scar.
to treat the back of the eye with inflammation, steroid injections to tissue SURROUNDING the eye is used or Oral steroids. if A cyst has formed under the retina, it would be treated today with an injection of a drug such as Avastin Into the eye. this stops new blood vessels from formingand it also stops blood vessels from leaking fluid which can cause the cyst (cystoid macular edema).
an OCT scan, optical Coherence Tomography to look at the surface of the retina and below is done when swellingis present, Fluorescein angiogram where dye is injected into the arm and then Photographs are taken to look for leakage and cysts and new blood vessels is also done when posterior uveitis, swelling form Cystoid macular Edema, new blood vessels might be present, the optic nerve requires a better look etc.

we have a list with specialists around the USA at http://www.uveitis.org in the PATIENT information section of the site. there is a doctor at the University of Arizona who studied at the National Eye Institute who may be able to help you to figure out what is going on and then to treat it appropriately, if you have an autoimmune or inflammatory disease, then a steroid sparing approach to treatment is needed. sometimes adding and oral NSAID can help but often stronger drugs called DMARD drugs for arthritis are needed. the Drugs methotrexate, cellcept or Imuran are most often used in a steroid sparing approach to treatment. the goal is off all steroids without inflammation to treat your eyes and any underlying disease process. once the eyes ar quiet off steroids, you stay on the DMARD drugs for at least two years. it takes teh immune system 2 years to respond an to stop producing the cells attacking your eyes when an autoimmune disease or inflammatory disease is the cause.

if you need help getting the contact information for the doctor there in Arizona, tell me and I'll get it for you.

wishing you the very best,
Mike
Mike Bartolatz
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Re: Iritis / Anterior Uveitis - Normal Experience?
by Mike Bartolatz on Fri Feb 08, 2013 5:56 pm

the herpes virus cause a lot of inflammation in iritis patients, it can extend in a circle around the entire iris, this can lead to increase pressure inside the eye. if you start seeing rainbows around lights or have pain get to an ER for if you cannot get in to the ophthalmologist or optometrist for a pressure check. you can start losing peripheral vision so make sure you are checking for this while taking steroids and while inflammation is present as there can be no other symptoms than slow errosion of peripheral vision. hte herpes sx virus doesn't respond well to steroids and they can actually make things work by suppressing the immune system and then the virus goes crazy. the iritis remains in ONLY ONE EYE BTW. If this worsens please get another opinion as oral antiviral meds are needed at prescription strenght if it is the herpes sx virus. there is a Lady at the Univesity of Arizona who trained at the National eye institute who is the expert in Arizona on uveitis. get an appointment with her.

vision will be blurry as long as you are on dilating drops and steroid eyedrops. it can take several weeks before the is totally rid of the drugs too once you stop them. when uveitis is successfully treated, vision usually goes back to about where it was before all of this stuff began. try not to worry too much but be vigilant and get the pressure checked indside your eyes. an injection into an eye with HERPES virus or any other pathogen is not advised BTW.

wish you the best,
Mike
Mike Bartolatz
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Mike Bartolatz

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Last comments for now. To me the steroids don't really seem to be doing much. Haven't helped in terms of clarity in vision (although they can make it worse by themself) and I haven't heard that the KP's have been reduced much. Based on that fact, I more inclined to think that steroids are not the answer. I will know more in a week, but I am inclined to push for the antiviral medication route. Does that seem reasonable?

[Mike Bartolatz]

Kerratic precipitates form on the back of the cornea, how they appear can help indicate potential causes of them. you have one hell of a lot of them if they are at a level 4.

lymph nodes swelling can be linked to sarcoidosis and this is why the chest xray. granulomatus uveitis linked to it as well as the herpes Sx virus. any form of granulomatus uveitis has a much higher likelihood that an autoimmune or inflammatory disease or pathogen is the cause of the iritis. if it remains in one eye, it is frequently linked to the herpes Sx virus especially when one has a history of canker sores. this can cause the iris to no longer function and it can cause glaucoma from an almost complete adhesion between the iris and the lens.

go to the 'review of opthalmology website and do a search on causes of Kerratic precipitates. it will give a description of types and links to various disease processes.

keep using the dilating drops while you have active inflammation even though they contribute to the blur of vision you mention. don't get a new prescription for glasses until about a month after you finish all meds as it can take that long for the eye to return to normal.

Wish you the very best,
Mike

[Mike Bartolatz]

http://books.google.com/books?id=0-bdGJ ... es&f=false

[bpasero]

Just wanted to provide an update. Since I first started seeing the retina specialist 6 weeks ago, my anterior uveitis / iritis is finally completely quiet. I am now tapering off the pred fort (PF) drops. I seemed to have lost a little distance vision in the affected eye, but not major. I also had a slightly larger dilated pupil, but that has now gone away after I missed my third and final drop yesterday. I was on a pretty strong dilating drop and I suspect the PF drops held some of it in my system. The doctor has me tapering from 4 drops/day to 1 drop/day and then none over a 6 week period.

For me this was very stressful because I wanted to know 'why?' However, in trusting my doctor, I was able to calm down and lower my stress level. Being the first case, or unilateral uveitis, the doctor felt that it was not necessary to stress and tax my body and mind by going through rigorous tests to find the reason. Unfortunately, many of the tests might not have even been conclusive anyway. For example, most people have herpes virus antibodies in their system, so that test might not be useful. I also had the pressure in my checked very frequently, especially in the beginning, which helped to put my mind at ease about pressure concerns for glaucoma.

All told, it took more than 2 months for my eye to quiet down (the KP's). For me, just knowing that it could take this long would have also put my mind to ease as well.

That said, everyone is different, but I just wanted to explain my situation. Hopefully this will be my last post.

Thank you to Mike for all your help and support. Along with the messages sent directly to me, I was also able to get answers about a lot of the other things associated with uveitis / iritis from other posts of yours. How to put in the drops, how dilation can change (temporarily), etc.

[Mike Bartolatz]

Glad things are improved for you. please keep us informed too as we like good news as well as requests for assistance.
Lets hope that you will successfully taper off the steroid eyedrops and that this will be your last bout of iritis.

take care,
mike

[bpasero]

Update:
No further bouts of iritis/uveitis and vision returned to normal. Had one year follow-up with a retina specialist and everything looks good.

However, I do have a floater in my eye that I am trying to get used to. It is most noticeable in bright lighting. At this point it is really just an annoyance, but I did want to follow-up on this board to document the case.

Thanks again!

[Mike Bartolatz]

The evidence that you had 'swelling' in the back of the eye is unusual in such early stages of iritis. this would indicate there is fluid build up from cystoid macular edema, having pain when moving the eye from side to side is also not normally a symptom of iritis and might be indicative of other systemic cause. if the lymph nodes remain swollen, get in for a biopsy. this could be found in Sarcoidosis for example and the only TRUE way to diagnose Sarcoidosis is through tissue biopsy. serum blood tests are of little value nor are negative Xray tests of the lungs. viruses can cause lymph nodes to swell too and the C word is a bit premature to consider.
the topical eye drops are only beneficial for inflammation in the front of the eye causing iritis, they cannot penetrate to the middle or back of the eye. steroid injections to tissue surrounding the eye are needed for this and VEGFR blocking drugs injected into the eye are needed for the posterior swelling/Cystoid macular edema.

KP's means keratic precipitate: Keratic means cornea so I don't understand what you mean besides this. often they will appear as 'stellate' (starburst) or candle wax drippings or mutton fat dripping in granulomatous disease associated with uveitis.
sarcoidosis has the latter if I recall correctly. perhaps the doctor meant that no signs of posterior exudate, behind the iris or of the posterior retina/macula when he said posterior KP"s.

will be here to help you whenever you return.

my best,
mike

[Mike Bartolatz]

Glad your eyes continue to be quiet. A large black floater can be sometimes a spot of blood so get in for re evaluation. this can be from a vitreous membrane trying to detach, vascularization of the retina/blood vessels breaking and bleeding, detachment of the retina from Cystoid Macular Edema. Only an Ophthalmologist can evaluate you for these things.

wish you the very best,
mike

[bpasero]

Hi Mike,

I did go to a retina specialist on Monday and she did a full evaluation on me. Checked for KPs - none. Checked my retina (shined a really bright light and looked in with a lens of sorts) and said there was no signs of detachment. I remember thinking at the time she told me that it was weird she was telling me there were no signs of detachment because I wasn't expecting there to be. However, now that I read what you wrote, I can see why she said that.

I know there are a lot of people out there that are a lot worse off than I ended up, but even with the one floater in my eye, it can be really annoying at times. Especially when a large amount of my work day is spent looking up at a computer. Since the floater is at the bottom of my eye, it helps if I look down on the screen.

[Mike Bartolatz]

level 4 on the KP's would be massive and would explain your obscured vision. just as cells are rated on a scale of 1 to 4 so all other things in the anterior and posterior segments of the eye. getting inflammation under control is the only way to get this number to go down. these are not cells but protein given off by the cells. they will flush out of the aqueous over time (mine did for example).

please be vigilant regarding your eyes. any change of vision should require a visit to the ophthalmologist because you MIGHT THINK your eyes no longer have problems but they can as the back of the eye, the macula can have problems and new blood vessels can grow in the retina and you wouldn't know it until your have major bleeding. flashes of light for example in your peripheral vision can be a sign of the vitreous tugging on the retina which can lead to bleeding or detachment especially in someone under about 55 years of age. (the vitreous detaches in most of the population in their 60"s). Flashes of light can also be a symptom of problems with the optic nerve as can pain inside the eye (pain is never normal). rainbows around lights can be linked to glaucoma, this can be from angle closure: the drains of the front of the eye become plugged up from inflammatory materials as they are being flushed out of the eye.

Hopefully none of this will be present in your future. I am just trying to educate not to scare you. if things develop, get to the ophthalmologist immediately or to the ER. the sooner your are seen, the better the long term outcome. some have no permanent vision loss if they get in right away. those who wait risk damage to vision that cannot be regained.

wish you the best,
mike